DSM Revisions in Psychiatry: How the Diagnostic and Statistical Manual Might Change Diagnosis

In this Science Quickly episode, Kendra Pierre Lewis talks with Alison Parshall about the Diagnostic and Statistical Manual of Mental Disorders (DSM) and why its future revisions matter. They explain how the DSM functions as a foundational reference for diagnosis, treatment and billing, and why critics argue that its categories do not reflect underlying biology. The discussion covers APA proposals to introduce contextual factors and biomarkers, while acknowledging that core issues may persist. The autism DSM-5 changes and the tension between clinical needs and scientific validity are explored, with the caveat that changes will unfold gradually through public feedback. The host notes that real shifts may take years, and offers guidance for patients and providers as this process continues.

Overview: The DSM as Psychiatry’s Foundation

The episode centers on how the Diagnostic and Statistical Manual of Mental Disorders, or DSM, shapes what clinicians diagnose, how research is conducted, and how insurance is billed. Alison Parshall describes the DSM as the “bible of psychiatry,” a description that underscores its central role in mental health care and research, while also acknowledging longstanding criticisms of its scientific validity.

"the DSM is considered the bible of psychiatry." - Alison Parshall

Background: Criticisms and the Drive for Change

Listeners are walked through the core criticism: DSM categories are reliable for doctor-to-doctor agreement but not necessarily valid reflections of biology. Neuroscience and genetics have shown substantial overlap among disorders and a lack of clear biological boundaries, challenging the idea that current DSM buckets map onto distinct disease entities. The conversation also contrasts clinical needs—clear diagnoses for patient care and billing—with research needs that aim to unpack the biology of mental illness.

"the underlying problem of the DSM is that it's based off of these categories that don't reflect biological reality." - Alison Parshall

Proposed Changes: Flexibility, Context, and Biomarkers

The APA committees are proposing a diagnostic framework that relaxes rigid categories, allowing clinicians to note a depressive episode without forcing a definitive label, and to include contextual factors such as homelessness or comorbid medical conditions. A biomarker component—while still largely theoretical for most mental illnesses besides Alzheimer's—could eventually inform diagnoses. The aim is to address criticisms about diagnostic validity while preserving practical tools for clinicians and researchers alike.

"There is no option to throw out the DSM." - Alison Parshall

Implications and Uncertainties: What Comes Next

Parshall emphasizes that these proposals are preliminary and subject to broad input from clinicians, researchers, and patients. The changes echo debates from the DSM-5 era, which ultimately retained much of the prior structure after pushback. The discussion also touches on how autism spectrum disorder became a broader, less discretely bounded diagnosis in DSM-5, illustrating the tension between nuanced understanding and the need for a workable framework. The overall tone is cautious: substantial reform may be incremental and could take years, with possible name changes and ongoing revisions.

"It could be years until we get something new." - Kendra Pierre Lewis